Compliance & Regulatory Requirements Flashcards

A healthcare organization's compliance hotline is most effective when it:

Answer: Allows anonymous reporting without fear of retaliation

An effective compliance hotline must permit anonymous reporting and protect reporters from retaliation to encourage employees to come forward with concerns.

Which standard under the Medicare Conditions of Participation addresses a hospital patient's right to make decisions about their care, including the right to refuse treatment?

Answer: Patient Rights standard

The Patient Rights Condition of Participation explicitly protects patients' rights to participate in their care decisions, including the right to refuse treatment.

Under the ADA, healthcare facilities must provide reasonable accommodations to individuals with disabilities unless doing so would cause:

Answer: Undue hardship — significant difficulty or expense relative to the organization's resources

The ADA exempts organizations from providing accommodations that would constitute an 'undue hardship,' evaluated based on cost, resources, and operational impact.

A covered entity that fails to have a Business Associate Agreement (BAA) in place when sharing PHI with a vendor may face:

Answer: HIPAA civil or criminal penalties for an impermissible disclosure

Sharing PHI with a business associate without a compliant BAA constitutes an impermissible disclosure, which can trigger HIPAA civil money penalties or criminal charges.

In healthcare compliance, a 'corporate integrity agreement' (CIA) is typically entered into between a healthcare provider and:

Answer: The Office of Inspector General (OIG) as part of a settlement to avoid exclusion

A CIA is an agreement between the OIG and a healthcare provider, typically part of a civil settlement, requiring enhanced compliance measures as an alternative to exclusion.

Title VI of the Civil Rights Act of 1964 requires healthcare organizations receiving federal funding to:

Answer: Provide services without discrimination based on race, color, or national origin

Title VI prohibits discrimination based on race, color, or national origin in programs receiving federal financial assistance, including healthcare facilities.

When conducting a HIPAA Security Risk Analysis, a covered entity must evaluate:

Answer: The potential threats and vulnerabilities to all electronic PHI it creates, receives, maintains, or transmits

A HIPAA Security Risk Analysis must comprehensively assess threats and vulnerabilities to all ePHI the covered entity handles, regardless of where it is stored or how it is transmitted.